At the end of 2007, 33.2 million people worldwide were living with the human immunodeficiency virus (HIV), and 95% of them resided in low- or middle-income countries. (1) Approximately 3 million people were receiving antiretroviral therapy (ART), (2) but an estimated 6.7 million were still in need of ART. (1,2) Although global initiatives such as the United States President's Emergency Plan for AIDS Relief (3) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (4) have focused on scaling up ART, millions of people living with HIV remain eligible for and could benefit from prophylaxis with co-trimoxazole (trimethoprim plus sulfamethoxazole, CTX), co-trimoxazole prophylaxis (CTXp) and isoniazid preventive therapy (IPT).

CTXp is a simple, well-tolerated and cost-effective intervention which can extend and improve the quality of life for people living with HIV, including those on ART. The value of co-trimoxazole in reducing the morbidity and mortality associated with HIV infection has been well established through clinical trials conducted in industrialized (5,6) and developing countries. (7-26) CTXp is associated with a 25-46% reduction in mortality among individuals infected with HIV in sub-Saharan Africa, even in areas with high bacterial resistance to the antibiotic. These improvements in survival have been accompanied by substantial reductions in severe disease events and in the number of hospital admissions linked to invasive bacterial disease, pneumonia, malaria and diarrhoea. In 2006, the World Health Organization (WHO) issued global recommendations for the use of CTX in children exposed to HIV as well as children, adolescents and adults infected with HIV. (27) WHO recommends CTXp for all symptomatic persons living with HIV who have mild, advanced or severe HIV disease (WHO clinical stages 2, 3 or 4) or for all persons living with HIV with a CD4+ lymphocyte (CD4) count < 350 per [mm.sup.3]. WHO also recommends CTXp for all infants exposed to HIV and all symptomatic children with HIV infection (WHO clinical stages 2, 3 or 4) and all children with HIV infection who have a CD4 count < 25%. Despite the proven clinical benefits of CTX and recommendations by WHO, the United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Children's Fund (UNICEF), its routine use in developing countries--particularly sub-Saharan Africa--has remained limited.

Tuberculosis (TB) is the most frequent life-threatening opportunistic disease among people living with HIV and remains a leading cause of mortality, even among persons receiving ART. Clinical trials have shown that IPT dramatically reduces the incidence of TB among people living with HIV. (28-36) A 2004 Cochrane Review found that IPT reduced the risk of TB by 33% overall and by 64% when targeted to people living with HIV who had a positive tuberculin skin test. (36) A recent retrospective study also showed that IPT significantly reduced the incidence of TB even among people living with HIV and receiving ART. (36) In 1998, WHO and UNAIDS issued a statement that recognized the effectiveness of IPT among people living with HIV and recommended its use as part of an essential care package for these patients. (37) This statement recommends IPT for all people living with HIV in areas with a prevalence of latent TB infection > 30% and for all people with documented latent TB infection or exposure to an infectious TB case, regardless of where they live. These recommendations were reinforced in a statement released by the TB/HIV working group of the Stop TB Partnership in October 2007. (38) WHO guidelines on essential prevention and care interventions for people living with HIV also recommend IPT for these individuals. (39) However, countries have been slow to adopt these recommendations and many limitations seem to be delaying effective nationwide implementation. In 2007, only 30 000 (0.1%) people living with HIV worldwide had started IPT. …

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